WIXLIB

AUTHORIZATION AND MEDICAL LIENiSCORE (Interventional Spine Care and Orthopedic Regenerative Experts)PO Box 8323, La Crescenta, CA 91214Tel: 818-338-6860; 626-460-1096; Fax: 888-425-9079Office: drmaxmoradian@gmail.com; Billing: billing.iscore@gmail.comI,desire to undergo an examination, consultation and any potential treatment regardingany possible injuries I sustained as a result of an incident causing injury (hereinafter the AClaim@) which occurredon/about. Having been counseled by the attorney of my choosing, I agree as follows:1. PROVIDER S LIEN. I hereby grantiSCORE/Dr. Maxim Moradian(hereinafter,"Provider") a lien on my Claim against any and all proceeds of any settlement, judgment, verdict, or award in theamount of Provider's standard billing costs for services provided to me or a family member for whom I am responsible.2. ATTORNEY AUTHORIZATIONS. I hereby authorize and direct my attorney of record,, Esq., and any subsequent attorneys (hereinafter "Attorney@), to pay Providerall amounts owing under this lien from the proceeds of my Claim before any payments are made to me. I furtherauthorize and direct said attorney to notify Provider of any subsequent change of representation regarding my Claim.3. PROVIDER AUTHORIZATIONS. I hereby authorize Provider to furnish Attorney and iSCORE, with all medicalrecords pertaining to my treatment, including reports on examination, diagnosis, treatment, prognosis, and othermedical bills on record.4. RESPONSIBILITY FOR PAYMENT. I acknowledge that I am directly and fully responsible to Provider for allmedical bills submitted for services rendered to me and that this agreement is made solely for Provider s additionalprotection and in consideration of Provider awaiting payment. I further understand that such payment is notcontingent upon any settlement, judgment, or verdict I may eventually receive on the Claim.5. INTEREST. Provider (or Assignee) shall be entitled to receive, and I shall be required to pay, interest at the rateof ten percent (10%) per annum on all amounts owed by me for services rendered by Provider. Interest shall begin toaccrue forty-five (45) days after settlement/judgment funds are received and shall continue until full payment of thisLien.6. MISSED APPOINTMENTS. I have been informed and agree that if I am more than 30 minutes late to anappointment, or fail to cancel an appointment 48 hours in advance, I may be billed 50% of the scheduled appointmentcharge by Provider.7. WAIVER OF HEALTH INSURANCE. I declare that I have thoroughly discussed with my attorney all possiblesources of funding for the treatment of my injuries including, but not limited to, commercial health insurance, healthmanagement organizations, and government programs such as Workers Compensation and have decided thatobtaining medical treatment on a lien is the best option. As such, bills for my treatment will not be submitted to anysuch health insurance program for payment.8. INTEGRATED/ENTIRE AGREEMENT. This Agreement, and Provider's statement of fees and costs whichwill be generated after treatment, constitute the final, complete, and exclusive statement of the terms of the agreementbetween the parties and supersedes all prior and contemporaneous understandings or agreements of the parties. Thisagreement may only be modified by a written statement signed by Provider (or Assignee of Provider) and myself9. STATUTE OF LIMITATIONS. I hereby agree to waive the running of any Statute of Limitations for anadditional period of four (4) years as provided in CCP 360.5.10. ACKNOWLEDGMENT. I acknowledge by my signature that I have read this entire agreement and that allprovisions, rights, and obligations have been explained to me by my attorney. As such, we consent to the terms ofthis contract and agree to be bound by it.PATIENT/ GUARDIAN SIGNATUREDate:, Esq. agrees that the attorney s status as trustee of the client funds will change from trusteeto debtor if attorney (1) pays any other party other than Provider for Provider s services, or (2) releases/forwards saidsettlement, judgment or award funds directly to client without paying Provider.; requiring Provider. to seek paymentdirectly from the client rather than the attorney.ATTORNEY SIGNATUREDate:Revised 02/26/2019

Interventional Spine Care & Orthopedic Regenerative ExpertsEmail:Attorney InformationLaw Office Name: Attorney Name:Law Office Address: City: State:Law Office Telephone: Law Office Fax:Law Office E-Mail: Law Office Contact Name:

Maxim Moradian, M.D.Physical Medicine and RehabilitationInterventional Pain ManagementSports and Electrodiagnostic MedicineInterventional Spine Care & Orthopedic Regenerative ExpertsPatient Name:DOB:DOS:NEW PATIENT DIAGRAM and PAIN SCORES0 No Pain10 The most pain you have ever felt in your lifePlease circle your CURRENT pain level (today) 0 1 2 3 4 5 6 7 8 9 10Please circle your HIGHEST pain level over the last week 0 1 2 3 4 5 6 7 8 9 10Please circle your LOWEST pain level over the last week 0 1 2 3 4 5 6 7 8 9 10FRONTRIGHTBACKPlease mark the figurewith the location ofyour symptoms.Pain Numbness # # # #Tingling # # # #DO NOT USE CIRCLES LEFT

Maxim Moradian, M.D.Physical Medicine and RehabilitationInterventional Pain ManagementSports and Electrodiagnostic MedicineInterventional Spine Care & Orthopedic Regenerative ExpertsNEW PMR & INTERVENTIONAL PAIN MANAGEMENT INTAKE QUESTIONNAIREName: Age: Weight: Height:What is your reason for visit?:How did it begin (suddenly, gradual, accident)?How long has this been going on?Is it constant or occasional?Is it getting worse, same, or better?Does the pain/discomfort go into the arms or legs? Which one?If pain/discomfort goes into arms or legs, is there numbness, tingling, or weakness?What makes it worse (examples - lifting, bending, sitting, walking)?What makes it better (examples - resting, sitting, standing, nothing)?Have you: (please circle)Lost control of bowel or bladder because of this? YES NO explain:Had prior x-rays, CT, MRI, bone scans for this? YES NO explain:Had previous spine surgery for this problem (what type)? YES NO explain:Had any spinal injections for this? YES NO explain:When? Did they help?What other conservative treatments have you tried? Physical Therapy/Exercise TENS unit Massage/Ultrasound Traction Manipulation/Chiropractic Cane Narcotic Medications Anti-Inflammatories Walker Cast/Boot Orthotics AcupunctureWhat other medical problems do you have? (eg Asthma, Diabetes, High Blood Pressure, etc)Allergies to any medications? Check box if No Known Drug Allergies Medication:Reaction:Medication:Reaction:Family medical problems? (eg Asthma, Heart disease, Diabetes, Cancer, etc)Father:Mother:Sibling:Do you smoke? current everyday smoker current some days smoker former smoker never smokedUse drugs? never in the past currently type of drug:Drink alcohol? never rarely socially frequently (more than twice per week) alcoholicWhat medications are you currently taking? (You may attach a list)What surgeries have you had in the past?Approximate date of surgery:

Please circle any of the following symptoms you have been recently vascular:ChillsNew LesionsBlurred VisionCoughChest Psychiatric:Endocrine:Hematology:Weight Gain/LossAbdominal PainBack PainFeverRashDouble VisionWheezingAbnormal BloodPressureNauseaJoint PainJoint SwellingMuscle PainMuscle Cold IntoleranceAbnormal BleedingHeadachesNumbnessWeaknessDepressionHeat IntoleranceBlood ClotsIncontinence StoolStrokeWeakness in LimbsHearing LossShortness of BreathJoint StiffnessDecreased RangeOf MotionSwelling ofExtremitiesIncontinence UrineTrouble WalkingExcessive SweatingEasy BruisingNone of The Above ApplyYour primary medical (family) doctor? Name: Tel #Address:City: State: Zip:Did a doctor refer you here, and if so who? Name: Tel #Address:City: State: Zip:OFFICE USE ONLY BELOW THIS LINE:Phy Exam: (pertinent positives)Vital Signs:IMAGING: [ ] MRI:[ ] L-Spine [ ] T-Spine[ ] C-Spine[ ] w/contrast[ ] CT:[ ] w/contrast (myelogram)Other:INJECTIONS:CONSULTATION:[ ] pre-op med clearance[ ] cardiac clearance

Interventional Spine Care & Orthopedic Regenerative ExpertsAuto versus Auto Accident Questionnaire1.Were you struck from: Behind Front Driver’s Side Passenger Side2. Were you wearing a seatbelt? Y N If so, what type? Lap Only Shoulder & Lap3. Were you the: Driver Front Passenger Rear Passenger4. Was your car pushed forward upon impact? Y N5. Did your car hit anything after it was hit?6. Did you lose consciousness (blackout) upon impact? Y N, If so, estimate how long?7. Did any part of your body come in contact with anything within the vehicle? Y NPedestrian versus Auto Accident Questionnaire (If applicable)1.Were you struck from: Behind Front Driver’s Side Passenger Side2. Were you hit while crossing the street? Y N3. Were you hit while on the sidewalk? Y N4. Did you lose consciousness (blackout) ? Y N, If so, estimate how long?Fall (ex: Trip/Slip and Fall) Injury Questionnaire (If applicable)1.Where did the incident occur specifically?2. Was an incident report filed?3. Were you hit while on the sidewalk? Y N4. Did you lose consciousness (blackout) upon injury? Y N, If so, estimate how long?Current Injury1. Have you seen any other doctor/ medical facility prior to visiting this office for injuriessustained as a result of the incident? Y N2. If yes, what is the name of the doctor/ facility you visited?3. If yes, what studies were performed? ( X-ray, MRI, CT scan, etc.)4. Did the police investigate the incident? Y N If so, what department?5. Did paramedics/ fire dept. arrive at the scene? Y N6. If yes, were you taken to the hospital by ambulance? Y NPrevious Injury1. Did you have a injury claim open at the time of this incident? Y N2. If yes, were you still receiving treatment for that claim? Y N3. Do you have any history of complaints in the area(s) reported? Y N4. If you have answered YES to question #3 above, what was your pain level from 0-10 (10being the worst), immediately prior to the above incident?5. If you have answered YES to question #3 above, were you under the care of anymusculoskeletal providers for the same areas immediately prior to this incident?